Writing with Scissors is the blog site of Howard Rodenberg, MD MPH, former Kansas State Health Director and columnist for the Journal of Emergency Medical Services (JEMS). He is a father, emergency physician, and slightly-past-fifty curmudgeon with great hair for his age. The "scissors" in question refer to those used by editors to weed out all things opinonated, controversial, or politically inappropriate...translated as "anything funny."

Saturday, October 31, 2009

I was invited to a Halloween party last week and was struggling with what to wear (I thought I might come as a caring and compassionate physician, but was told that someone had already beat me to it). So it was off to the seasonal Halloween Discount Worlds in the Abandoned Big Box Stores for an expedition into holiday spending.

It had been years since I had gone shopping for a Halloween costume, mostly because it had been years since I had been to a Halloween party. It’s not that I have any objection to costumes or parties. In fact, during my tenure as the State Health Officer in Kansas, I dressed up as both an intestinal polyp and as Major Molar. And while I really like going to parties, working an ED schedule and the inevitable fatigue of child rearing and middle age eventually take their toll.

So I was totally unprepared for the wonders of the modern Halloween Discount World. But I was glad to see that despite those who see Halloween as an unholy day, spiritually was alive and well. People were dressing as pastoral leaders like Popes, Rabbis, Priests, Nuns, and Sexy Nuns. All was well in the world.

The divine presence was lost, however, in the next aisle. This could best termed Groins Alive. These are male-oriented costumes whose greatest asset seems to be the ability to repel any vaguely attractive girl it encounters. These costumes feature the gynecology group of Dr. Howie Feltersnatch and Dr. Seymour Bush (names embroidered on the lab coat…their parents must be so proud), the Chief Instructor of the Mike Hunt Diving School, and a Mr. Hunglow who plays for the New York Yankers. (This reminds me of my Vietnamese colleague, who is fond of saying in his singsong accent, “Someday we go to strip club and you find out why girls call me Hung! Hahahahahaaha!”) Slightly more creative, and significantly less offensive, is the Chick Magnet outfit, which consists of a large stuffed magnet-shape pillow worn around the neck a bunch of puffball fowl glued to it.

The Breathalyzer and the Big Top Circus costumes featured a similar theme. The former is essentially a box you wear around your torso, with the “inlet” valve, if you will, strategically located around the groin area. (There is no guidance offered on the package as to who should take the test…apparently, it’s a matter of personal preference.) The latter is a kind of skirt shaped like a circus tent that you wear around the waste. The circus tent opens in the front, according all a view of the performing elephant. (I’m deliberately avoiding all references to the name “Jumbo” because I suspect that for those who would wear this kind of costume, the term need not apply. I am avoiding any references to “peanuts” because while this term may, in fact, be an accurate reflection of the wearer's assets, I can internally gloat while exhibiting public sensitivity.)

There are other outfits as well. There are the adventure-themed costumes like gladiators, pirates, soldiers, knights and cowboys; the animal costumes like pigs, penguins, and cows with squirting udders; and the truly fun costumes like pieces of fruit or the one where there’s a blow-up ostrich around your waist and your legs stick through so it looks like you’re riding the ostrich (riding in the correct form of the word, to be sure). And then there are the ones that are so tasteless as to have no redeeming value (the Blind Referee, complete with cane) or the ones I simply don’t understand (the Tightey Whitey, which seems to be a large pair of white underpants extending from groin to neck). But while there are dramatic costumes, eerie costumes, and funny costumes, at least they bear some resemblance to what they purport to be. Which brings us to the Super Mario costume, which does not look like a little mustached guy in red overalls and a jaunty yellow cap, but instead looks like Aladdin with the baggy pants and open vest topped by a hat which can best be described as a cross between the Hagia Sophia and a hallucinogenic mushroom.

Interestingly, female costumes show nowhere near the same range of styles. All of them…and it’s a bit of a generalization, but not much…are in the “Sexy (or synonym thereof) x” variety, where x = a character. (Like the way we worked some algebra n there? We strive to be both entertaining and educational job.) So we get Sexy Leprechaun, Flirty School Girl, Hot Pirate Wench, Luscious Demon Mistress, Buxom Geisha Girl, and the like. Certainly there are no realistic costumes like Frustrated Housewife, Underpaid Waitress, or Desperate Botox Silicon Cougar. What I found most intriguing is that there is an entire line of “Sexy x” costumes available for the oversized girl as well. I applaud this move as long as we recognize that at a certain point, bigger is not better. My experiences during Bike Week in Daytona have taught me that once you break 300 pounds, neither fishnets nor chaps are attractive. This goes for the guys as well.

To be fair, there are no realistic guy costumes, either. You never get a chance to portray a Dead End Manager or Petty Bureaucrat or Convenience Store Worker or Errant Weatherman. The latter is a shout out to my friend Jeremy, who is a local television weatherman…I’m sorry, that’s meteorologist…in Topeka, Kansas. When I worked an ED shift that got out at 10:30 and his last broadcast ended at the same time, we’d get together at 11 at a bar called Pigskin’s that had half price food after ten (translated as “eat this or we have to throw it out, and we may as well make some bucks on it while we can.”) I think Jeremy felt safe at Pigskin’s. We’d been out places during the day where people would come up to him and accuse him of misreading the entrails of the climate sheep, and he would very patiently explain to them the difference between a forecast and a prediction, and everyone would be thrilled that a TELEVISION PERSONALITY spent time talking to them. At the bar, it was much more likely that someone would come up to me and scream “HEY! I STILL GOT THAT RASH AND MY GIRL WON’T TOUCH IT ANYMORE!”

One costume I didn’t find was the Illegal Alien. You may have heard of this, as it recently was in the news:

A Southern California immigrant rights group has asked Target stores to stop selling an "illegal alien" Halloween costume it says is offensive to immigrants.

The costume…features the mask of an alien with a green card and an orange jumpsuit with "illegal alien" written across the front.

Angelica Salas, executive director of the Coalition for Humane Immigrant Rights of Los Angeles, says she wrote an e-mail to the Minneapolis-based retailer Friday calling the costume "distasteful, mean-spirited, and ignorant of social stigmas and current debate on immigration reform."

(Associated Press, October 16, 2009)

I agree that the costume is clearly inappropriate. In fact, I believe it is our solemn duty, as Good Americans, to welcome any green-faced antennaed aliens into our society with open arms. We must embrace them and share with our national blessings so we all, together, might realize our fondest hopes and dreams. Then, and only then, is it appropriate to send them out to a Secret Government Lab in New Mexico and dissect them to see what makes ‘em tick. And we should do so wearing snappy serapes and sizeable sombreros, all of which are readily available at the Halloween store and apparently cause no one any grief.

Costumes are not limited to the human variety. There is also a large selection of costumes for dogs. I always wondered about people who dressed up their dogs for Halloween until I became the pet of a beautiful young lady Shetland Collie who bit potential human female rivals for my affections and trained me to drop food on the floor at strategic intervals. In exchange, she would occasionally submit to wearing holiday gear. (Actually, getting a costume on a dog was a lot easier than I thought. The first time I saw them, I thought you had to actually get their little legs into the outfits. Turns out you just tie them around their necks.) The Princess apparel was tolerated; the Cheerleader sweater found the pom-poms devoured within moments (“they LOOKED like food”). The best dog costume at the Halloween store this year was the Yoda outfit, with a brown sack-like robe you tie around you dog’s neck and green headgear that I’m still not sure stays on without superglue. (“Good it is that my lips do not you kiss me on. Know not what I have been eating nor know what licking I have been.”) This year’s effort at animal couture has been the application of a jester hat to the Residential Cat. That lasted about three minutes, but the look of utter disgust on the feline face was well worth the five bucks. And I’ll recycle the hat and put it on my six month old nephew.

(Admittedly, in a shameless plug for which I am receiving no reimbursement, the best dog costumes are at Target. They have a lobster suit that’s a killer.)

Of course, it’s not all costumes at the Halloween Store. There are the other accoutrements of the holiday, including all varieties of tombstones, snakes, spiders, rats, assorted bagged vermin (30 bats for $7.99), disembodied organs, hacked-off limbs, severed heads, necrotic fanged infants, axes, swords, scythes, plastic vibrating chainsaws, and other cheery holiday fare. Not a lot of distinction, however, though I was favorably impressed with the motorized rubber rat tugging at the throbbing plasticine heart, as well as the life-sized Hannibal Lector display that kept flipping off its mask and saying things like “I’m having a friend over for dinner.” (The gourmet food industry must have hated the Silence of the Lambs. Pate can be a pretty tough sell to start with, promotion on Top Chef notwithstanding, but now…) And for those who wish to celebrate in a literary fashion, you can get both a glow-in-the-dark skull and a stuffed raven so you can quote both the Bard and the Baltimorean at the same time.

But after all this shopping, I realized I had the perfect costume at home. And at the party, I realized that the best costumes, of course, are the ones you don’t expect. Yes, there was the requisite guy with the Barack Obama mask, but he carried a briefcase full of beer that he called his “stimulus package.” (He could have called something else his “stimulus package,” but he properly acknowledged that you have to respect the office.) And then there was the couple who were dressed in normal clothes, but had a necklace of rope attached to a flat wooden piece of playground equipment. (I’ll let you figure out that one…took me about a half hour myself.) And I learned many other useful things at the party, including that the people you work with actually have bodies when they’re not wearing scrubs, and that it’s weird to see three different people all wearing Brett Favre Green Bay jerseys with foam cheese on their heads in the middle of Florida, and that if the ability to get a whole jello shot out of a medicine cup with your tongue is a measure of intimate prowess I may as well give it up and go home.

Thursday, October 29, 2009

There are very few things in medicine that yield instantaneous results that please nearly everyone. The ones that do are usually quite simple.

Take the case of Mr. Barnes, who came in today unable to hear out of his left ear. He didn’t know why, but a single glance told me the whole story. Unknown to him, a swarm of honeybees had invaded his otic canal and constructed a very very very compact hive. It was dense, it was thick, and it was the color of the Big Mac Special Sauce when it’s had a chance to congeal a bit. (And for the record, I have eaten that.)

Most people don’t like the process of getting wax out of ears. It’s wet, repetitive work, an entry-level job serving as a rite of passage to doing more useful things such as taking rectal temperatures. However, I think its’ great fun. The trick is to dissolve away the wax just enough to create a small gap between the wall of the ear canal and plug. One you’ve got the hole, you irrigate the daylights out of the ear with warm water under high pressure (like generated by a squirt gun or a syringe with a plastic tip). If done right, the water flows through the gap and builds up pressure on the other side of the wax, and the cerumen (that’s the doctor cocktail party word for it, and why we can bill so much more than you) pops out whole for you to display to the astonished onlookers as the patient shouts out “I can HEAR! Thank the LORD!”

(The method also works with foreign bodies like pencil erasers. I know this because one of my other patients today was a young man who had just been named the “Most Inspirational” member of his high school class for his pastoral work. What he was inspired to do today was to place a pencil eraser on the sharp end of a pick-up stix and poke it in his ear to see what would happen. Using the above method, this popped out whole as well. I’ve been promised a “shout-out” in his next sermon. I’ll take all the heavenly points I can get…got a feeling I’m gonna need them someday.

This effect is even more dramatic when both ears are affected. Let me serve as an example. About two years ago I started to have trouble hearing. I had a feeling like both of my ears were blocked, and having had some sinus problems in the past I figured it was just a chronic buildup of fluid in the middle ear. But weeks went by and a continual diet of decongestants never seemed to help. To be honest, it wasn’t all bad. I’d go to meeting where I knew I was going to be asked some question that I couldn’t answer, and the “I’m sorry, can’t hear well, got an ear problem” excuse gave me some extra leeway to respond eloquently to a question other than the one asked. But I was trying to pull this off one morning with a pediatrician in attendance, and in calling my bluff he suggested that I drop by the office later that day.

So at noon I’m sitting in a chair in his office, looking up at happy elephant stickers perambulating across the ceiling, getting my ears hosed out with a high-pressure squirt gun by two nurses who are trying, but not succeeding, to stifle a snicker at the predicament of the State Health Director. I have to tell you that the sensation of the ears getting cleared out was really quite amazing…one moment you simply hear a low rumble of the water shooting against the wax, then a second later you hear the roar of a tsunami wailing on your eardrum, along with some nausea and dizziness induced by the water’s chill. (This is known as the caloric response, for those of you keeping score). And for the first moments I could hear everything…the whine of the neon lights, the hum of the air handling system, the traffic in the parking lot…all the noises we filter out during our daily life because they’re just too common. It was mind-numbing, one of those moments when you are simply overwhelmed in a way that defies description, like when you come over a hilltop to see an unexpectedly glorious valley below. It’s a very transient feeling, a few seconds at best, and then your mind readapts to it’s usual mode of work. I don’t know that I’d go out of my way to do it again…at least not with the ear wax…but definitely an experiential moment of note.

Speaking of ears (hahahahaha), one of the other instant cures is getting a live bug out of an ear. The best method to resolve this problem (translated as the funniest mode) is the Pedal Technique. You place the patient in a dark room, and shine a light into the ear canal. Just like cockroaches on your kitchen counter, the bug will run from the light. It exits the ear canal and the patient jumps up screaming. The cockroach falls to the floor and the physician steps on it. That’ll be $40.00, please.

Wednesday, October 28, 2009

Despite the protestations of the right, I really do believe Rush Limbaugh is an entertainer. I believe this because entertainers make hay with political correctness is order to provoke, amuse, and grow rich. So while Rush, the Reverend Al Sharpton, and Glenn Back are crazier than loons (and that's a very grave insult to the loons, one of America's finest community waterfowl), at least they never struggle with the language of the PC crowd.

One of the hallowed terms in clinical medicine is "non-compliance." A patient is non-compliant when they fail to follow a prescribed course of care. The non-compliance may be overt, as in a patient who simply tells you there's no way he's going to rehab for his alcohol problem; or it may be covert, like when the patient tells you they're taking their blood pressure pills when the prescription actually never got filled. The term suggests an active and conscious effort to resist the suggested plan of medical care. It's a term that over the years we've applied broadly to any patient who doesn't do exactly as we say. (I would put in a real-world caveat here that it shouldn't apply to those who have legitimate religious reasons for refusing certain aspects of care, but technically the term would apply to them as well.)

However, in my own personal nod to the PC culture (and putting yet another nail in the coffin of my nascent career in stand-up comedy), I'm consciously trying to use a different term when I see patients in the ED. While many people do not follow through with their plan of care, in many cases it's not their choice. Sometimes they truly don't have the money to afford theirmedications. Sometimes they may not qualify for any assistance program that allows them access to a physician. Sometimes they lack transport to the doctor's office. Sometimes their medical condition prohibits their compliance with aspects of care. Sometimes they may be confused and take too much or too little of their medications. And sometimes they may simply be acting like human beings and just forget. Researchers have proposed the term "non-adherent" to these patients who would actually like to comply with care but for reasons other than their own are unable to do so. And while the term smacks of political correctness it actually makes clinical sense.

I think some of my colleagues in the ED would say that I give patients a harder time about compliance than some of my peers. Despite the attitude I consciously try to project, I take seriously the role of "fighting the good fight" to use our health care resources wisely. (It's a leftover of a public health career I'm still working to shake off.) So while I have no problem with the system caring for you at taxpayer's expense...if fact, I believe it's the morally right thing to do...I also believe that the individually has a responsibility to take the benefit offered by the system and use it appropriately in order to achieve the end goal of health. So I think that as we look at health care reform, and recognize that the primary way to achieve the simultaneous goals of quality, cost constraints, and access to care is to place some limits on benefits, it's important to try to ferret out the differences between patients who are non-complaint and those who are inadvertently non-adherent. The former group may lose access to care; the latter should be facilitated to maximize their chances of following the medical plan. The trick for policymakers, of course, is how to accomplish this on a national level. The trick for me is to keep the difference in mind in the middle of the night.

Tuesday, October 27, 2009

11:30 PM Leave ED to head home after evening shift. Fight urge to stop at Taco Bell due to sudden vision of non-roughage food items descending through aging GI tract coupled with fresh memories of colon cleansing infomercial seen last night. Take a moment to remember Gidget the Chihuahua. Wonder if Les Nessman still believes the dog is really called a chi-hoo-a-hoo-a. Sing WKRP theme song in head. Promise to look up lyrics to second verse online. Recall that turkeys don’t fly. Oh, the humanity of it all!

Midnight: In door, shoes off, leftover spaghetti in microwave. Acknowledge presence of cat. Continue to be gracious to cat as it follows me into kitchen. Introduce cat to science of aerodynamics as it jumps on kitchen counter.

12:17 AM: Spaghetti prepared. Bow placed next to laptop, which is now aglow with a steely blue stare and challenging me to write. Log onto blogspot.com. Think of interesting anecdotes, important issues, or response to news items to share with loyal readers who, as best I can tell, number me and my sister. Wonder if it would just be easier to call her.

12:35 AM: Got nothing. Log onto Fantasy Football site. Place waiver claims for Cardinals defense. Lament over the fact that in order to win, I have to pick against my own team. Rationalize selection of offensive stars working against Kansas City by saying that it’ll be a 56-48 game, with the Chiefs on top. Know that despite inside information and throwback jerseys featuring Buccaneer Bruce, still will not select the Tampa Bay defense.

12:53 AM: Recall amusing comment made to me by our ED pediatrician about patients and cellphones. Wonder if I could adapt it to my piece on new vital signs published earlier in the blog, with the amount of time you spend on the cellphone being an inverse measure of true emergency need.

1:06 AM: Nope, that didn’t work.

1:08 AM: No new emails, either.

1:10 AM: Or Facebook news.

1:12 AM: I have no friends.

1:15 AM: Look up from laptop to find cold spaghetti bowl being licked by cat.

1:30 AM: Fire up computer game in effort to relax and stir the creative juices for blogging. Recognize early that this is an excuse, as I ‘m really annoyed because I can’t break through the last mission of the Terran Campaign in StarCraft: Brood Wars. See, what’s happened is that the United Earth Directorate has come to clear this sector of the Zerg, a race of fanged and carapaced arachnids who know nothing but death and conquest. The UED has found the Psi Disrupter and the Zerg broods are in disarray. But the Overmind must be pacified in order to eliminate the threat to humanity. So I need to eliminate the three Cerebrates still loyal to the Overmind, each of which has a specific mode of defense, and then use medics to inject the Overmind with a powerful neuropoison. Hope that’s clear.

1:59 AM: Where did that Ultralisk come from? And forgot to save the game. Damn.

2:41 AM: Battlecrusiers kill Ultralisks. But now Battlecrusiers can’t target ground defenses…must be one of the unique Cerebrate defense modes… so my guys can’t get through to mine more crystals so I can build up my fleet. I should’ve read the hint book. But I have integrity.

4:30 AM: Success! The Zerg are destroyed, the sector preserved for humanity. We regret the loss of our brave comrades, but rejoice in their victory.

4:31 AM: Exit game. Look at time clock. It’s 4:31 in the freakin’ morning! How did that happen?

4:38 AM: Trying to get to sleep. Counting sheep fails because instead of numbers, sheep get names appropriate for their color of wool and overall personality. Mind wanders to humorous stories involving lonely individuals and companionate sheep. Laugh out loud. Cat looks puzzled.

4:42 AM: Angry. How many nights have I wasted with this game? And with the original StarCraft? Or Warcraft? Warcraft II? Warcraft III? Civilizaiton III? Civilization IV? The Warloards Expansion? Age of Empires? Age of Empires II? The Conquers Expansion? Age of Mythology? Age of Empires III? And that’s not even addressing all the television I’ve watched. My life is gone, the opportunity to make a difference in this world vanished like the temporary intimacy of a girl and a six-pack under the wrong circumstances. I wanted to be an astronaut, a United States Senator, a well-known author. Instead, all I have to show for my time on earth are some hollow victories on the “easy setting” and the unsettling knowledge that fourteen-year-old boys with no life experience are waaaaay better at these games than I am, and that when I am old these same children will be Congressional Staffers running the country.

4:48 AM: Reassure self that Starfleet Command II was never a waste of time.

4:51 AM: Under the covers, counting again. Wonder if ex-wife has anything in common with Zergovermind. Thought recurs that that if I had avoided wasting my life, I really could’ve been a contender. But then would not know WKRP theme song. Trade seems fair. Nod to Pepys. “And so to bed.”

Monday, October 26, 2009

The town of Protection lies just before the Red Hills of Southwest Kansas, an area of rugged scarlet gypsum crags that looks as if it came straight from the Acme-painted landscape of a Road Runner cartoon. It’s a small town of about 500 people, and with apologies to John Mellencamp it’s like most small towns in rural America…one bank, two restaurants, a tribute gallery to the local boy made good (in this case Stan Herd, the crop artist…stop laughing and check out www.stanherdart.com); a town that’s aging, hurting, patiently awaiting it’s long-known fate. Nobody knows how the town got it’s name. One version says it was the result of a joke, when cowboys faked an Indian raid to frighten the settlers and the townspeople collected under a bluff for protection. There’s another story, and a better one, too:

"About a year later a post office was started on the Kiowa and called Protection. Among the prominent members of the old Protection Town Company were E. P. Hickok, W. P. Gibson, J. W. Johnson and one or two others, all republicans, good and true. When it came to selecting a name for the new post office, there was some difference of opinion, and it was finally agreed to leave the naming to the postmaster general, who was a republican also. In the political platforms of those days there was much said in regard to "protection," as compared with "free trade," when speaking of the development of American industries and the employment of labor, and it was but the natural thing for the postmaster general to think of the word "Protection" for the new post office on the Kiowa in Comanche-co., Kansas. That, as I understand it, was how the city of Protection got its name." -- Hiram O. Holderby, The Western Star, April 8, 1921.

Even then, Kansans were nothing if not conservative.

The town of Protection is important because its name led the National Polio Foundation to make it the first community in the United States to have everyone under 50 years of age immunized against polio. Today, we can’t conceive of what threat polio was to children, especially during the summer. My father recalls times when no one was allowed to use public swimming pools or engage in other summer fun because of the spectre of polio. And while many of us have seen pictures of Franklin Roosevelt (probably the world’s most famous victim…and conqueror…of polio), the only way today to get a sense of what polio was like is to lay for a time in an old iron lung and imagine that you may, or may not, be able to leave it. Now imagine yourself, or your son or daughter, lying there as an uncomprehending four-year old. The advent of the Salk injectable polio vaccine, and the Sabin oral vaccine that followed, resorted the joy of childhood for millions in this nation and around the world.

Immunizations are one of the true success stories of public health. Most authorities would rank vaccination and the provision of clean drinking water as the top two achievements in health over the last century, besting antibiotics, hospital care, or surgery. (A health wonk like me would want to point out that, according to the CDC, fully 25 of the 30 additional years of life expectancy over the last 125 years have come from the world of public health, and not from the health care system.) Vaccines work so well that when there is an even a small outbreak of measles or mumps, it becomes newsworthy. Vaccination is proof that science works. So it’s disturbing to see that bad science is being used to link vaccines…and specifically a preservative contained within vaccines called thimerosal… with neurodevelopmental disorders such as autism. It’s especially worrisome when aggressive vaccination is one of the key tools we have to prevent the further spread of pandemic H1N1 “swine flu.”

The concern over mercury compounds such as thimerosal is linked to the idea that the presence of these chemicals in vaccine products can retard neurologic development, and more specifically results in autistic disorders (clinicians refer to autism not as a specific condition, but as a term applying to range of problems known as “autistic spectrum disorders,” or ASD). It is true that there is a correlation between total body exposure to mercury and impaired neurologic development. As a result, in 2001 the Institute of Medicine (IOM) recommended that thimerosal be removed from all vaccines administered to infants, children, or pregnant women in the U.S.

On the surface, that single recommendation would suggest the case is closed. There’s a link, the Institute of Medicine said to remove the thimerosal, and why would they do that if it wasn’t the cause of autism and other developmental delays?

The spinmeisters keep trying to tell us the world works in sound bites, but most of us know better than that. Sound bites represent a fraction of the larger discourse, just as exposure to mercury in one venue does not reflect the total exposure to this element. A careful reading of the IOM report shows that the recommendation was a precautionary step to limit the cumulative exposure infants might have to ethyl mercury. The concern of the IOM was not based on the dose within the vaccine, but on the cumulative dose of mercury received from environmental exposures, such as eating fish laced with industrial mercury wastes and mercury leeching into the fetus from dental amalgams. This hypothesis is supported by studies that document a lack of link between thimerosal in vaccines and the development of neurologic disorders, but suggest that cumulative environmental mercury exposure raises the risk. The IOM felt that the mercury in vaccines was a controllable exposure, whereas that in the environment at large was not. Therefore, as non-mercury alternatives could be identified, they should be used. Their recommendation was seen as a step towards mitigating a larger problem, and certainly not as a “cause-and-effect” solution unto itself.

Nonetheless, there continues to be a belief that any mercury in a vaccine is necessarily the cause of neurologic abnormalities, especially when used in combination with the MMR (measles, mumps, and rubella) vaccine. Knowing that measles virus can cause encephalitis in severe cases of clinical illness, the theory contends that measles virus is absorbed into the body through the vaccine and that the thimerosol in the vaccine product both alters the appropriate immune response and poses a direct toxic effect, resulting in an inflammation of cerebral tissues resulting in autism. Much of this belief comes from the work of Dr. Andrew Wakefield, a British doctor who led the initial works claiming a link between autism and the MMR (measles, mumps, and rubella) vaccine. While the studies were ripe with flaws, press coverage insured that the effects of his work on vaccine uptake in the United Kingdom were immediate and significant. A Canadian source notes that, “At one point MMR vaccination rates sunk to 75 per cent in Britain, well below the 95 per cent authorities say is needed to keep these diseases from circulating. While the rate has since climbed to about 85 per cent, Britain continues to suffer outbreaks of these three diseases and to seed the diseases abroad (CTV.ca, July 16, 2007).” We’ve seen similar things happen in the United States as a result of unthinking publicity. For example, Kansas saw that in the summer of 1999, there was a dramatic drop in the number of Kansas newborns receiving immunization against Hepatitis B after a recommendation to suspend vaccination with this agent due to thimerosal content in the vaccine. A thimerosal-free product was released four moths later, but even now we still have yet to see a return of vaccination rates to 1999 levels.

(Interestingly, the Wakefield saga continues to this day. In 2004, ten of his collaborators retracted the work, and it was later revealed that Wakefield was doing research for pay on behalf of parents who were seeking legal damages from vaccine companies. He had also taken out a patent for a new form of the vaccine, providing possible incentive to bias his results. He is now facing revocation of his medical license from the British General Medical Council.)

The medical community, recognizing the value of vaccination, was quick to respond. A brief search through the National Library of Medicine collection revealed over 130 papers reviewing the links between thimerosal, vaccines, and neurologic development within the past decade, and both the United States Centers for Disease Control and the Institute of Medicine have reviewed the issue in depth.

The bottom line is that the studies have failed to establish a firm link between exposure to thimerosal in childhood vaccines and the development of neurologic disorders. One of the best works was performed in Denmark to review the incidence of autism in over 500,000 children before and after the advent of laws mandating that all vaccines be free of thimerosal. In that nation, the incidence of autism continued to rise despite the lack of thimerosal in the vaccinations (JAMA 2004; 291:180-1). On our side of the pond, the California Department of Public Health just this year published work which demonstrated identical results (Arch Gen Psych 2008; 65:19-24). Clearly, there is something that is behind the rise in these developmental disorders. It may be environmental, genetic, or (I suspect) related to both the appropriately increased awareness and diagnosis of the spectrum of ASD as well as the harmful societal urge to “medicalize” behavioral issues in order to divert accountability. But there certainly appears to be no cause-and-effect link between vaccine use and the development of autism.

As might be expected in this country, the vaccine-mercury-autism issue has a legal dimension as well. Over 5,000 families have filed adverse event claims with the National Vaccine Injury Compensation Program (NVICP), claiming a causal link between the MMR vaccine, thimerosal within the vaccine, and neurodevelopmental delay. Three test cases were selected for adjucation, and in all three cases claims for compensation based on an alleged thimerosol-autism link were denied early this year by Special Masters appointed by the United States Court of Federal Claims. (In all three cases, the denial was upheld on appeal.) The basis for these denials was well summarized as follows:

“After considering the record as a whole, I hold that petitioners have failed to establish by preponderant evidence that (the child’s) condition was caused or significantly aggravated by a vaccine or any component thereof. The evidence presented was both voluminous and extraordinarily complex. After careful consideration of all of the evidence, it was abundantly clear that petitioners’ theories of causation were speculative and unpersuasive. Respondent’s experts were far more qualified, better supported by the weight of scientific research and authority, and simply more persuasive on nearly every point in contention. (The) parents brought this action in good faith and upon a reasonable basis. However, they have failed to demonstrate vaccine causation of (the child’s) condition by a preponderance of the evidence.”

(United States Court of Federal Claims, Office of Special Masters, No. 01-162V, February 12, 2009)

All this being said, most of those involved in the debate still don’t recognize that since 1999, the only commonly used childhood vaccines containing thimerosal are the influenza vaccine (and specifically only the vaccine found in multi-dose vials) and the combination vaccine against both hepatitis A and B (there are thimerosal-free forms of vaccines against only hepatitis A or B, but none in combination). In many ways, the thimerosal question is one of the past and not of the present.

From a public policy standpoint, it’s not just the concern of bad laws being derived form bad science. Laws requiring all vaccines to be mercury-free may impact the ability of state and local governments to prepare for public health outbreaks such as the current spread of H1N1 influenza. While thimerosal-free influenza vaccine is available, in recent years only about 10%of the total supply is manufactured in that form. The most cost-effective and efficient way to immunize children against this virus is through the use of multi-dose vials that contain thimerosal. Children do die of influenza and its complications, and the limitations of these policies mean that children may be at risk of not being able to receive the vaccine they need.

Some proposals may truly enter the realm of “unintended consequences.” Several years ago, there was a bill proposed to eliminate the use of any drug product containing mercury in Kansas. This meant that adults, as well as children, may not be able to receive influenza vaccination from multi-dose vials. They may also not be able to receive travel vaccinations such as those against encephalitis. Snake and spider antivenins also contain mercury products as preservatives, as do many prescription and “over-the-counter” products for the eyes, ears, and nose. We’re fortunate that in Kansas, the legislature has not passed any such bills out of committee.

So if the science is bad and the thimerosal is gone, why are we having this dispute? In my view, this is one of those areas in public policy where personal passion meets the public stage. I’m very blessed to have a happy and healthy eleven-year-old boy. If my son had autism, I’d be doing exactly what the proponents of these laws are doing. I’d be looking for an answer, something that I could see as a cause for the condition, and I’d be doing what I could to prevent it from happening to others. Knowing that, hearing the heartbreak in these parent’s voices and seeing them struggle with their children, it’s hard to look at the issue objectively. I just wish I could agree.

Saturday, October 17, 2009

In the summer of 2006, it was hot in Topeka. Very hot. Record-breakingly hot. Swimming-pool-and-bath-water-what’s-the-difference hot. Even lizards are unhappy hot. So hot, in fact, that when the character of Blue in the Cartoon Network show “Foster’s Home for Imaginary Friends” was watching an animated weatherman note that there were showers in Spokane and that it was hot in Topeka, the latter phrase quickly morphed into a frantic chant of “It’s hot! My toe is hot! I’m a hot toe picker. Pick my toe!” Needless to say, he was rapidly adopted as a community icon, and virtually everyone could be found sitting on their doorstop in the evening shade picking at their pedal piggies. (See for yourself at http://www.youtube.com/watch?v=AzdWMcLvn2g.)

Of course, Al Gore would tell us that in the future, we’ll all be hot (and presumably it’ll be HOTTER in Topeka, in which case we’ll be picking the toes of otters). But while most people in our polarized world see climate change as an either/or problem, a battle between “greens” and “greenbacks,” it’s always been interesting to me that the real battleground is this country is not in the heavily populated or industrialized states but in rural America. Certainly there are articles and stories about ethanol production, and every now and then you’ll hear about some work on using bovine methane as an energy source (and if you’ve ever hung around a feed lot, you have no doubt as to that potential). By and large, however, rural America is often thought of as immune to energy politics, except when trying to determine how many cows you can displace for a wind farm.

But in Kansas, energy politics dominated the legislative process for the past two years and virtually paralyzed the rest of state government. At issue was the decision of the Secretary of Kansas Department of Health and Environment (KDHE) to reject a permit for building a coal-fired power plant in Southwest Kansas. The reasons for and against the plant are too numerous to mention in this brief piece, but essentially it became a conflict between legislators from poorer rural areas who wanted development versus those from relatively more affluent urban areas who were more eco-friendly. But what I think is most unfortunate about the situation is that it bodes poorly for national efforts after health care reform, as energy policy and “cap and trade” are next on the President’s Wish List. For just as the West Coast tends to be a harbinger of social change, for better or for worse Kansas has always been ahead of the curve on political conflict. (While Republicans nationally are now recognizing the depth of the schism within their party, Kansas has essentially been a three party state for a decade. Of course, we put our own twist on it…our parties are Libertarian Conservatives, Traditional Republicans, and Conservative Democrats who would be considered Liberal Republicans anywhere within 60 miles of either coast.)

As some of my readers know, I was the Director of Health within KDHE during the time of this decision, though I was not directly involved in it. Shortly after leaving the state agency, however, I was asked to summarize for some legislators what we do and do not know, from the perspective of science and health, about global warming and specifically what it would mean to a state like Kansas. With the winter coming up, energy costs rising again, and the President’s focus on energy policy, it seems like the time is ripe to revisit the issue, with some specific attention (and a shout out) to that place I still call home.

The Warm Earth and Greenhouse Gases

To properly begin this review, it’s vital to note that the earth normally goes through cycles of global warming and cooling. These cycles are a result of a number of a number of factors, the most significant of which is the relative quantity of “greenhouse gases” in the atmosphere. Less important drivers include solar variation, subtle changes in the earth’s orbit, plate tectonics, volcanism, and the manner in which the oceans distribute heat. (Try getting all that into one sentence at a cocktail party.)

The role of “greenhouse gases” is critical to note. The atmosphere of the earth can be thought of as a “closed” system, within which no substance save energy (heat) can get in or out. Greenhouse gases are those molecules within the atmosphere that trap the sun’s heat energy within the atmosphere, preventing it from being radiated into space and, in turn, radiating the energy back to the surface. These gases include water vapor, carbon dioxide (CO2), methane (CH4), and other compounds. They are crucial to maintaining normal global temperatures; without them, the mean temperature of the earth’s surface would hover just below 0 F. Not all greenhouse gases are created equal; a molecule of methane has 23 times the Global Warming Potential, or GWP, than a molecule of CO2. (This gets us back to the cows, suggesting that if we all go to Chik-Fil-A more often, we can combat global warming.)

Increased amounts of greenhouse gases within the atmosphere lead to increased surface temperatures. For example, increased surface temperatures induce evaporation of ice sheets and bodies of water, increasing the content of water vapor in the atmosphere. This increases global heat retention, and the cycle is magnified and begins again. The planet Venus, often thought of as the “twin” of the earth, is an example of a runaway greenhouse gas effect. It’s atmosphere is composed mostly of carbon dioxide, and it’s barren and arid surface bakes at over 872 F, hot enough to melt lead. From the standpoint of human activity, increased temperatures increase demand for cooling of homes and business, driving up CO2 production at power stations and further increasing the temperature, which again drives increased energy demands and further CO2 production.

What is Climate Change?

It’s important at the outset to differentiate weather from climate. Weather refers to events that occur in the “present,” over days or perhaps weeks. Climate describes the overall character of events and conditions as measured over time (decades, centuries, or more). This difference is critical, for you’ll often hear that the presence of a cold snap argues against a theory of global warming. Similarly, a heat spell cannot be taken n and of itself as evidence of climate change. (While the contemporary debate rightly focuses on global warming, climate change is actually a more correct term to use because it describes epochs when the earth cools as well.)

As previously noted, the earth normally undergoes cyclical climate changes of both warming and cooling throughout history. In the context of the history of the earth, we are still technically in an ice age (defined as a time in which sheets of ice continue to cover areas of the planet). We happen to be in a warmer period of the current ice age known as an interglacial. This is important to note because glaciers have been recognized as a sensitive early indicator of climate change. But just as weather cannot be taken as an indication of climate, the fact that we still have ice on the planet does not argue against the concept of global warming. This key difference is emphasized by noting the current retraction of the glacier sheet across the globe.

While climate change is a long-term natural phenomena, there is unmistakable evidence that the normal cycle of global warming is being accelerated, and that the cause of this acceleration is human activity (“anthropogenic” factors). The majority of the impact is caused by the burning of fossil fuels such as oil and coal, followed by the production of methane though large-scale agricultural production. Both of these activities produce “greenhouse gases,“ which are significant drivers of global warming as we‘ve discussed. Interestingly, cement manufacturing also accounts for a small percentage of CO2 release. There is also a human influence on global warming based on land use patterns, deforestation, and development, but this effect is marginalized by the contributions of greenhouse gas production.

Since the 1850’s, CO2 levels have risen from 280 parts per million (ppm) to 380 today, and if they continue on the current trend they would near 600 ppm by the end of the century. CO2 levels are known to be higher now than at any time in the past 750,000 years, and it‘s speculated that they are higher now than at any point in the past 20 million years.

Predicted Effects of Climate Change on Health

The increase in CO2, and the accelerated “greenhouse effect,” lie behind the predictions of a mean global temperature change of up to 6 C during our children’s lifetime. Rises in global temperature are considered to result in rises in sea level and changes in agricultural production, biodiversity (species extinctions), the number and severity of extreme weather events, and significant effects on human health.

It’s somewhat more difficult to specify the effects of climate change on an individual state like Kansas. The climate of Kansas features a large air mass division across the middle of the state, which is one of the reasons for the stark differences in the ecology between the forested eastern half of the state and the high plains that characterize the western plateau. As a result of this air mass, different parts of Kansas could expect to see differing effects in an era of global warming. Eastern Kansas will become wetter, while western counties will become drier and more arid. Experts in climatology would be better equipped to provide more detailed estimates of the effects of climate change on both the agricultural industry and upon the parks and wetlands of Kansas. But you can guess that if’s it hard to make a specific prediction for an area as large as a state, it’s all the more difficult to determine the effects global warming on a local area, or of a greenhouse gas producer on its’ immediate proximity.

The predicted health effects of climate change fall into five major categories. The first is that of temperature-related death and disability. This category includes direct effects such as heat strokes and heat illness, as well as indirect effects such as stress on other organ systems induced by heat. The second relates to changes in rates of vector-borne (mosquitos, et al) diseases due to hotter, wetter environments. Problems linked to air pollution represent a third broad class, and increases in food and water-borne disease encompass a fourth. The fifth category includes the negative health effects of extreme weather events such as tornadoes and flooding.

In Kansas, it’s probably safe to say that all of these categories would be likely to apply. However, it should be noted that these effects are posited to occur in a regional sense at best. Models do not yet exist that can accurately predict specific local effects. This being said, thinking specifically about Kansas a final possible health effect comes to mind. Climactic changes may also result in decreased agricultural production and crop-shifting. While it’s unlikely that Kansans will suffer from nutritional disorders as may occur in the undeveloped world, these events may influence the economic well-being of the state.

Mitigating the Effects of Climate Change

While climate change is inevitable over geologic time, human activity is clearly accelerating the timeline of events, making the consequences of global warming something our children can expect to confront rather than an event in the remote future. As someone interested in public health (where I’ve always said you can be a paid professional liberal), I hope to see the human effects of climate change minimized. So let’s briefly review some strategies that can be used to prevent worsening of the problem.

There are three main strategies to mitigating these effects. The first is to simply eliminate the means of production of greenhouse gases. Industries and means of transportation that produce greenhouse gases are no longer sanctioned and alternatives, such as solar or wind power, must be identified and developed. Speaking strictly from the standpoint of efficacy, without regard for the economics of the issue, it is the most immediate way to curb greenhouse gas emissions.

A second strategy is to get rid of the greenhouse gases produced. For example, carbon dioxide can be taken up by a “sink,” a reservoir used to remove CO2 from the atmosphere. Examples of this strategy include reforestation, in which the large-scale planting of trees encourages CO2 uptake in the process of photosynthesis. Encouraging plankton growth in bodies of water and adapting agricultural processes are other examples of “natural“ ways to enhance CO2 removal from the environment. “Artificial“ methods include carbon capture during the combustion process and injecting CO2 into underground geologic formations such as oil fields, coal seams, and saline aquifers.

Each of these methods is controversial to a degree. For example, there is some debate as to the efficacy of reforestation given different climatic and geographic conditions; and in many cases, experience and technology have yet to fully support the theory. Nonetheless, they do offer real potential and, in my own view, should be aggressively explored as part of a comprehensive, cutting-edge energy plan

The third strategy is to maximize the energy output per unit of greenhouse gas created, therefore decreasing the “carbon footprint” of the total amount of energy produced. This can be done in two ways. The first is by influencing the process of production itself, using technologies to burn fuels more efficiently with less “off-gassing.“ The second is the use alternate energy sources to increase the total amount of energy produced per unit of greenhouse gas. On a small-scale, this is what hybrid automobiles do; they use the power from the combustion engine to charge a battery, which provides more power for the auto given the same amount of fuel used than a traditional gasoline engine. Supplementing fossil fuel power plants with wind or solar energy projects is a larger model for the same basic concept. Combustion of agricultural methane to produce both energy and CO2, a gas with a lower GWP than methane, is a variation of this idea.

I have deliberately left out the idea of “carbon offsets” in this discussion. The term is most often thought of as an economic tool where permits for industry resulting in greenhouse gas production are “traded” for dollars to be used elsewhere to remove or reduce other emissions or develop alternative energy sources. But scientifically, it means simply that if carbon is released into the atmosphere through one mechanism, something else removes it form the air so there is an even balance of production and disposal. In this sense, the use of “carbon offsets” is most similar to the sequestration strategies noted above.

All of these are large-scale mitigation strategies. To my understanding, accurate models do not yet exist that are able to predict how much or how little any single project contributes to global climate change, nor how much or how little any particular strategy will mitigate these effects. One is not necessarily preferable to the other, and all are reasonable and logical ways to approach the problem. This being said, if we acknowledge that global warming is a reality and that human activity is accelerating the process to our detriment, it is my personal belief that we have an obligation to begin to lay a groundwork for change using any or all of our options.

That being said, a friend has just told me that on this Friday night in mid October, it’s rainy and cold in Topeka. Cold rain on my toe. My toe has a cold. Pick that toe!

(And just for the record, the only other mention of Topeka in popular culture? The remarkable Loretta Lynn lyrics that remind us:

“But here in Topeka, the rain is a fallin'The faucet is a drippin', and the kids are a bawlin'One is a toddlin,' and one is a crawlin'And one's on the way.”)

Thursday, October 15, 2009

Mr. Johnson came in a few weeks ago with shortness of breath that had been going on for three months and an extremely weak answer to the question, “And what is the medical emergency brings you to our Level II Trauma Center at 2 AM today?” His care was routine, but every now and then when interviewing a patient you come up with a gem. Looking at his chart, he claimed an allergy to American Cheese.

Granted, allergies mean different things to different people. Some people may consider an expected side effect as an allergy. Drugs such as erythromycin and narcotics are known to cause gastrointestinal effects such as nausea and vomiting. Other allergies may be a result of more patient-specific intolerance of the medication at a certain therapeutic level, such as patients who become excessively sleep or dizzy at a certain dose of anti-hypertensive drug but do fine at a lower level. (Interestingly, before drug levels became available some drugs were dosed by side effects. The right dose of digitalis, a drug used for heart failure, was the dose one step lower than the one that made you throw up.) A true allergy is a full-fledged joyride for histamines, mast cells, basophils, and lots of other mediator you’ve never heard of, all heading down the autonomic highway. The patient with true allergy develops hives, shortness of breath, and swelling throughout the body but most dangerously around the lips and tongue that can result in total airway obstruction. And when one has a true allergic reaction to one member of a family of drugs, we will shy away from any of the members of that family in order to avoid precipitating the same reaction with a chemically similar agent. (Knowing this, some of our drug seeking patients manage to have allergies to all but their drug of choice. On the other hand, when they say they are allergic to codeine abut can take the closely related oxycodone just fine, that’s doesn’t add up, either.)

I’ve been accused of sometimes thinking way too much, and so the allergy to American cheese caused me great mental consternation. You just knew he had to be faking this, because everyone is aware that hypoallergenic plastic is the major component of American Cheese (just as velvet is the prime constituent of Velveeta.) So I wondered if he had any problems with foreign cheese? No, he was probably happy to feast on foreign cheese, especially of those countries that failed in their duty to join the Coalition of the Willing. Little pansy countries in Europe that get their cheese not from big strapping corn-fed cows in industrial-strength hermetically sealed dairies but from little scampering goats of questionable manhood that frolic about the hillsides to the sounds of Zamfir and the Pan Flute (“He’s sold more records within the NATO alliance than David Hasselhoff!”).

Yep, that was it. Clearly he despised our country, our government, our way of life, the very foundations of our land. But he was smart: he knew that to air his wrath publicly would put his life in jeopardy, so he subtly declared his hatred of all things good and noble and American (because all three words mean exactly the same thing) through his alleged allergy to our cherished national processed food product. No doubt he was the kind of guy who probably kept saying French Fries when any Real American called them Freedom Fries, the same Real Americans who would also eat Freedom Toast in the morning and ask thier girlfriends to wear lacy Freedom Maid costumes for Halloween. And he had some nerve with that attitude in Daytona. Down here, in the wake of 9/11 there was a joke…no, not really a joke, but a statement of fact…that hitting NYC bought the terrorists time to hide while the media reacted, the government examined it’s options, and a response plan was put intoplace. If they had hit the Daytona 500, all the survivors would have filed out of the track, got their firearms down from the gun rack in the back of the truck, and called two buddies to put three extra can of gasoline and a really big cooler in the bass boat. War’s over.

(Speaking of foreign things, one of my colleagues has made a new rule. He will not see patients with foreign bodies unless the offending object has a green card. And if there’s no green card, he plans to extract misplaced item, enclose it in a box, and ship it back to whatever country it might belong. Which is exactly what we were going to do during my internship to an illegal immigrant who had been in a chronic vegetative state and on a ventilator in Kansas City for over a year. A senior resident, an intern, two students, a Ryder truck, and lots of oxygen tanks...but that’s another story.)

Saturday, October 10, 2009

Doctors get asked from time to time what we think of health care reform. (We also get asked about swine flu, and spend a considerable amount of time explaining that you cannot contract the disease from Sweet and Sour Pork.) I used to try to follow the debate to the letter, but realized it was silly to do so when nobody making the policy actually did, either. So here’s what I understand as of now:

Health care reform was intended to give every American full access to the health care system. It was intended to stabilize or decrease health care costs while enhancing the quality of care. It was intended to reform the health insurance industry, and to make the lives of physicians and other health care providers easier by decreasing paperwork and releasing them from the burdens of unrealistic expectations and medicolegal fear. The net effect of the entire effort was to improve the overall health status of the nation. These are all laudable, important, and urgently required goals.

But so far, what we’ve got is a proposal that forces all Americans not already covered by Medicare or an expanded Medicaid to purchase an “affordable” health insurance policy or face a federally imposed fine. In order to help lower-income families purchase insurance, we will be using government money to support the purchase of polices from the same insurance companies that have been the leaders in denying, restricting and raising the costs of health care coverage so that administrative costs now represent a third of our health care dollar. Yes, we will allow public co-ops to develop insurance plans as well, but these will operate in the same mode as traditional insurance companies and will, in essence, differ only in ownership and profit margins. (In fairness to the co-ops, there is a model that works for them. It’s called Medicare). The out-of-pocket deductibles for low income families purchasing insurance, and the choice of using family dollars to buy insurance or pay a fine likely smaller than in the coverage costs, even with a subsidy? Not even a whisper of a question.

Physicians, of course, will not be finding their workloads eased nor have more time for quality patient care. While all Americans may be insured, the paperwork per patient stays the same, and there is still no relief from the lawsuits that result when the physician is unable to meet the consumer demands irregardless of the quality of care provided. Reimbursement still favors procedures rather than thought, technology instead of counseling, and the drive towards increased specialization and a reliance of testing rather than clinical insight remains unabated. (Oh, wait a minute; there’s going to be a panel. That’ll make it all better.) That is, of course, assuming that these newly enrolled patients have physicians to see them: Many physicians already decline to see Medicaid patients (or see them only when required to do so, as when “on call”) due to perceptions of patient compliance and medicolegal risk. There is no reason to believe a new flood of Medicaid patients will be greeted by enthusiastic doctors and hospitals, and those who do assume the burdens of care will do so facing declining reimbursements despite increased demands for accountability.

Am I missing something?

It seems to me that if we’re serious about health care reform, let’s do it seriously. If the underlying principle is that all Americans should have access to a baseline level of health care, then we should design health care reform as we would any other program that delivers basic services to which everyone should be entitled. If we view health care as a fundamental benefit of living in this country (the question of health care as a “right” or a “privilege” is temporarily shelved for another day), then we need to determine the appropriate level of entitlement, institutionalize it, and provide it without cost to all citizens of the United States. Those who can afford more certainly have the privilege of doing so, but are still responsible for their share of the common good.

The public schools can serve as an example of this precedent. American society has determined that education of our children through at least age 16 (10th Grade) serves a social good of such import that we require all children to receive this benefit. Granted, individual schools may differ in quality, but we have as a collective body decided that every child has a right to an education, and we have institutionalized this right through school statues, infrastructure, and funding sources. Those who opt out of the baseline benefit (sending a child to public school) can choose to do so at their own expense, but are still required to contribute to the general welfare. To make it more plain (and put it in a health context), we have determined that within the United States, every person should have access to clean water for drinking. We institutionalize this belief through laws, regulations, and infrastructure such as sewer pipes and water treatment plants. This baseline level of service doesn’t stop anyone from spending a few extra dollars for a water softener or filter, but those with own systems are still responsible for supporting the public works.

So if we’re serious about health care reform, let’s be serious about it and build reform around the fundamental desires and goals of the effort rather than what can get past the lobbyists. Let’s take the time to determine what clinically represents the baseline level of care that should be expected by every American, and let’s find ways to build in a set of responsibilities for each beneficiary to match the entitlement they’ve been granted. Lets’ change reimbursement patterns to reward primary and preventive care. Let’s revamp he system of medical justice. Let’s invest powerfully in information technology to allow doctors and hospitals to “talk” to each other within a secure framework of patient care.

But let’s not go as far as to restrict health care to a single payer system, thus denying those who can desire and afford further benefits to obtain them. The advent of a public benefit will likely be in competition with private insurance plans, and the latter may lose some business. But it also provides them with an opportunity to streamline their corporate structures, revise and enhance their product lines, adapt marketing strategies to maintain their volume and market share and, in the process, make health insurance truly affordable for all. It seems to me that’s essentially a “conservative,” free market idea that co-exists quite nicely with the more “liberal” agenda. (I believe that the idea I‘m discussing is fundamentally different than a “public option” insurance plan…the difference between a public and a private option coverage is simply a matter of where you send the bucks. Nonetheless, establishing a defined minimum level of benefit for all citizens will likely result in some of the same competitive challenges and opportunities for the private sector.)

Of course, if a fundamental shift in how our system works is not what anyone was actually thinking…well, as Miss Emily Litella used to say, “Never mind.”

Thursday, October 8, 2009

Medical tradition has held that there are four vital signs. They are the pulse count, respiration rate, blood pressure, and temperature. While nobody’s asked me, I presume they are called vital signs because, with the possible exception of popsicles like Walt Disney, Ted Williams, and the crew of the SS Botany Bay (KHHAAANNNN!), one simply cannot be vital without them.

Even now, the measurement and interpretation of vital signs remains one of the most important aspects of clinical care. One of the cardinal rules of Emergency Medicine is that you can’t send a patient home unless you can explain or correct any abnormal vital signs. Vitals signs also serve as the miser’s lab test, a low-tech, no cost indicator of patient status. It is to the detriment of medical practice and art that in our hurry to build volume and bill technology, vital signs are either neglected or cursorily acquired without any of the real-world interpretation encompassed in actual patient observation. Vital signs help to interpret patient complaints; it’s hard to assess a patient who says they have a fever when no temperature was ever taken (an unfortunate side effect of many “no wait” ED triage systems). Similarly, careful assessment of vital signs and matching them with the clinical status of the patient is something technology cannot achieve without human interpretation. It would good to know if the patient is cool and clammy because they’ve just been in the pool or their blood pressure is zero. (Admittedly, that last one was hyperbole. The fact is that when you have no blood pressure, the sweating stops. As does your pulse, your respirations, your ability to think at a level higher than Jessica Simpson, and most other things we associate with life. It's a corollary to that wonderful surgical rule that reads "All Bleeding Stops. Eventually.")

But modern medicine, just like the Value Meal at McDonald’s, is all about more. If four vital signs were good, five must be better. And so about thirty years ago it became popular to add the Glasgow Coma Score (GCS) to the hoary hierarchy of health. In brief, the GCS is a measure of neurologic status based on eye opening, verbal response, and the ability to move the limbs to stimuli. The score ranges from 3 to 15, three being a comatose state and 15 being awake, alert, oriented, and able to say things like "it's important that we engage in constructive dialogue with the Iranian leaders" without laughing (oh, wait..maybe I got it reversed).

The GCS is actually a very cool invention, one about which I have waxed, if not eloquently at least pedantically, in some previous work for jems.com. However, what I’ve always found most fun about the GCS is that if there is no response to a measured parameter, there is a natural assumption that the score should be zero rather than one. It’s nobody’s fault…nothing equals zero in most other facets of life, so it’s a deeply ingrained pattern of behavior. But the GCS doesn’t work that way, which is why from time to time you’ll get a call from a paramedic indicating that the GCS is 0, which as far as I can tell is better than dead.

For the last decade it’s been in vogue to add pain to the list as well. This idea is based on work documenting that physicians often undertreated pain. In addition, pain became one of the criteria by which a patient must receive an emergency evaluation and stabilization exam under the tenets of federal EMTALA (Emergency Medical Treatment and Active Labor Act) legislation. Pain control then became a rallying cry for patient’s rights organizations, often to the extent that the idea of clinically appropriate pain control was turned on its head. At one point during my tenure as Kansas State Health Director, there was even a bill put up before the legislature with a clause that would require physicians to treat a patient’s pain in a manner best determined by the patient, not the physician. That's not a bad idea if patients have terminal cancer, who in my book are entitled to any medication they want. But it's not a good idea if the law is intended to satisfy patient demands regardless of need.

(I could write any number of other pieces on this blog about how we deal with drug seekers, in the ED. I know some of my colleagues get frustrated by them, but dealing with these patients for me is a game of Clue in real time, my own personal version of CSI. There is the part where you do your clinical job, ferreting out behavioral and exam clues as to the true nature and severity of pain; there is the part where you check out the story and gather other background materials through phone calls and old records; and finally there is the moment when you synthesize the data, open the envelope with the cards, and declare the case solved.

I won’t go into great details about how ED docs do this for fear of giving away some of our deductive powers. But let me simply offer this single point of advice: We know where the telephone is and we know how to use it.)

The cunning linguists among you (always wanted to work this line in somewhere) will note that a sign is an objective finding, while a symptoms is a subjective sensation. This definitional problem has led to the creation of a number of pain scales in an attempt to standardize an inherently variant phenomenon.

The most interesting are those that ask the patient to rate the pain on a scale from one to ten. One of these scales notes that a pain level of ten is the worst pain you can imagine. This scale appeals to the philosopher in me. If you can imagine something, then you can imagine something greater, and imagination is by definition infinite. So according to this scale, no pain can ever reach ten, because you could always imagine just a bit more pain than you have, and then you can imagine just a bit more pain than that. It’s the same paradox that has Zeno’s tortoise winning the race no matter how fast Achilles could run and how little the head start.

Then there are the scales that establish ten as the level at which you would do yourself bodily harm to be rid of the pain. If that’s the case, then instead of using drugs for pain relief the most cost-effective way to handle the problem would seem to be an informed consent for euthanasia. (But I hate taking business from Dr. Kevorkian.) The scales that are the most fun are those that establish ten as pain so bad you’re unconscious, because when the malingering patient says to me they have a pain level of 10 I can look at them and say, without judgment or malice, that they’re lying because they’re still talking and not unconscious (in which case you don’t have any pain, right?).

I’ve been thinking about vital signs lately because last week I thought I had stumbled on the Next Big Thing in Vitals. It was The Moan. In the ED one hears a lot of patient noises, and it’s important to be able to distinguish between those sounds which suggest a person in distress and those which indicate your life is about to become difficult. So as the ambulance brought in a young woman whose moans suggested the latter was to be my immediate fate, I wondered if volume, pitch, or frequency of the moan could be used as an index of illness severity. My initial hypothesis was the volume of the moan was inversely proportional to the degree of acute pathology; the louder you yell, the better your lungs and heart and the less likely you are to actually require emergency care. (Actually, when I initially thought of this I wasn’t using such polite terms. My train of thought was less clinical and much more directed at the assumed personality characteristics of the said producer of the industrial-strength holler. But I’m sure you get the drift.)

I ran this idea by a wise, weather-beaten colleague of mine, the kind of guy who doesn't recognize narcotics more potent than two fingers of Jack and an old poster of Farah Fawcett. He quite rightly suggested that moaning in and of itself was a non-specific indicator with poor specificity, sensitivity, and predictive values. (And they say there's no academic talk in community hospitals. Look at all those big words, huh?) He pointed out that many patients have a perfectly valid reason to moan and probably ought to be allowed to do so without fear of labeling. Folks with kidney stones, for instance, should and do moan. People with mangled limbs are not only expected to moan, but have the God-given right to do so. Patients with acute cardiac events may also moan to themselves as they briefly reflect upon their lives (those who rise up out of bed and shout, "Elizabeth! I'm comin', honey!" are a different matter entirely). So if I was going to pursue this line of reasoning and develop a powerful clinical tool, clearly more thought was required.

I started to reflect on other markers that might contribute to my new index of patient non-distress. For example, three weeks ago the ambulance brought us a young woman who was dying. We knew she was dying because she would emerge from her exam room, stride up to the nurse's desk, loudly proclaim “I’M DYING” while asking for pain medication, and saunter back to her room until the next matinee 2.83 minutes later (6 episodes in 17 minutes...yes, it was timed). When I finally had an opportunity to visit with the patient (after seeing two other patients who were not only not moaning, but not breathing as well) I discussed with her that I felt comfortable saying that she was actually not dying because those who usually are often do so quietly and seldom make a habit of getting up and notifying us of their impending demise. So perhaps one of the parameters for my new vital sign should be related to the number of times you walk away from your bed to tell the nurse of your imminent discharge to the celestial floor.

A third thing I want to fit in is the number of previous visits to the ED. In general, those who use the ED more frequently tend to have less severe illness on presentation. (Again I’m using polite language here, although in person I will often ask our “Frequent Flyers” if they’re getting companion tickets for their dozen visits this year alone. But to show you how medicine has evolved, twenty years ago when I started I would ask they were getting Green Stamps.)

By themselves, none of these parameters meets the level of significance needed for a valid clinical measure. We’ve already mentioned that there are entirely valid reasons for moaning, and there are some truly unfortunate people with terrible progressive disease who do require frequent ED visits. So in order to make this work, combining the measures into a single equation seems to have the best chance of providing an accurate measure of patient non-severity. So as of 5:47 tonight, here’s my winning entry:

(Decibel volume of moaning) x(Nursing desk visits for death proclamations) x(Number of previous ED visits in past 24 months for same complaint) =Non-Severity of Non-Illness Index (NSNII, or The "Rodenberg Score")

(You may have noticed that even in the few pieces I've already submitted to this blog, I keep naming stuff after myself. There are two main reasons for this. The first is that, like Beowulf, a large part of me believes the way you survive after death is through the fame you've achieved in life. In medicine, fame is to be an eponym. The other reason is that the only thing that ever actually got named after me was a local EMS prehospital seizure treatment protocol that used rectal valium, a procedure that came to be known as a "Rodenberg ." I would much rather have my name covered with some other form of glory than...ummm...sheizure.)

Like most things in medicine, a few caveats must be kept in mind. The score cannot be applied to children less than 12, because you simply can't choose your parents. (One of the saddest things I know is to see bright and happy little kids in the ED, and then look at their family and realize the child has no chance in life.) And it’s also considered invalid in nursing home patients, because tradition dictates that they be shipped out to the ED every time they roll over in their beds, accidentally pinning the remote under their hip and turning off The Real Housewives of Beverly Hills during shift change. (And there are three shifts each day.)

I look forward to your help with this research effort. Additional contributions are welcome. But it'll still be called The Rodenberg Score. Just so we're clear on that.

Tuesday, October 6, 2009

In the Blue Ridge Mountains of VirginiaOn the trial of the Lonesome Pine…”

Oliver Norville Hardy, Way Out West, 1937

My son and I have developed a number of Daddy and Boy traditions during our decade together. One of them is movie night, where we select a favorite from our large collection of Laurel and Hardy films. He makes an innovative dessert (usually a base of ice cream with Lord only knows what he throws in there), we eat popcorn and drink Coke, and with any luck neither of us pukes up these culinary creations. Another is the “Nature Walk” (or, as he calls it, “A Fate Worse Than Death”), where the child is forced to troll through neighborhood parks and walking trails in the company of his parent and is encouraged to converse about things in the real world like school and friends and karate class, and is constantly reminded that, dagnabit, some day he’ll be grateful for this time together. I have to ask him about school during these walks, because when I ask him on the phone I’m continually astounded by the fact that he can spend seven hours in a building with hundreds of other children and do absolutely nothing. Here’s how those conversations go:

“Did you do any reading today?”

“No.”

“Did you do any math?”

“No.”

“Did you do any science?”

“No.”

“Did you do any social studies?”

“No.”

“Did you eat lunch?”

“Yes.”

“Did you use any oxygen?”

“Yes.”

“Did you sit on your thumb and spin?”

“No.”

This routine has become so well established in our conversations that now all I have to do is ask, “How was school today?” to hear him say, “Nonononoyesyesno.”

We also have Automotive Song Time, during which I sing spontaneous ditties while driving such as “All Praise to the Father” (Sample lyric: “All praise to the father. He’s better than the rest. All praise to the father. Of dads he is the best.”) while he cringes in the back. One of our newest habits is the Sunday Morning Breakfast, where we head to a local coffee shop and get some cups of hot chocolate while we read the comics and explore the internet. This week it was special selections on You Tube. He showed me the Kittycat Dance. I showed him the video of Peyton Manning from Saturday Night Live. We accidentally opened an email with a very grown-up picture of a young lady from Grandpa. Fortunately, the child has books about the human body at home. Minimal explanations were necessary.

I was showing him my piece on jems.com about soccer, and how I had featured his rear end as a central point of that missive. (For those who missed it, I told the tale of his greatest athletic triumph, making a save in five-year-old soccer when the ball hit his backside.) He thought this was interesting, and then asked if I could write something for him on the internet. I would have been ecstatic if he had wanted to write it himself. For a ten-year old, my son is a brilliant writer, a creative genius in Spider-Man sneakers, and this isn’t just the Daddy talking. He’s won countywide school creative writing contests for his age group, and for ages he’s been dictating ideas and stories to me that I type up for him. For example, several years ago when my brother’s wife was expecting, he created a wonderful gift for my sister-in-law where he asked folks to provide baby advice and then put all the responses in a keepsake album. It seemed logical to me to ask the person in my household who was closest to babyhood (in age, not maturity…that would have been me) what advice he might give. Here are a few excerpts from his list:

Babies are important to take care of.

The might spit out their food, so watch out!

If you treat the baby the way it wants to be treated, then the baby will treat you the way you want to be treated.

Do not feed the baby beer!

Keep the baby away from Lego pieces or they will eat them!

Babies are nice, so do not wake them up when they are napping.

Do not say, “The baby has a beard.”

(And who among us has not wanted to note that the baby has a beard?)

He also got quite frustrated when he read in the newspaper that Pluto was taken off the list of planets. Here’s his unsent Letter to the Editor:

Dear News,

I am mad you say Pluto is not a planet! Pluto was an emblem to me. An emblem of the small kids. I think all of you should get a new job. May I suggest a job selling door-to-door ham? Pluto is important to me. It is my favorite planet! MAKE IT A PLANET AGAIN! I will keep doing this until Pluto is back as a planet! So, I think you should give Pluto another chance. DO IT OR ELSE!

Your protestor,

Brendan Rodenberg

So it was with great fatherly pride, and a desire to avoid work for as long as possible while attempting to hit Level 70 on “Cradle of Rome” (available from Real Arcade.com), that I offered him the opportunity to write a column for jems.com. Unfortunately, he declined with all the politeness and tact that a ten-year-old can muster when asked to do something by a parent whom he is beginning to perceive as flawed in some vital way, but can’t quite put his pre-teen finger on it.

“That’s dumb.“

Hoping for clarification, I asked what exactly was dumb about it. He informed me (in no uncertain terms) that all I write about is medical stuff, and that was boring. He did say, however, that if I really wanted to write something useful it would be about Lemony Snicket, the eponymous author of the series of children‘s books titled “A Series of Unfortunate Events.”

(I should probably note for the record that the reason my boy thinks that all things medical are silly is likely a direct result of the way I‘ve handled the usual childhood emergencies. I suspect that like most of us involved in emergency care, if someone is generally doing well we quickly lose interest. So his experience has taught him that if he gets hurt, I‘ll ask him “Is it bleeding? Is it attached?” If the answer to the first question is no, and the answer to the second is yes…and he‘s able to answer the questions, which means his ABC‘s are intact…and if he stomps his feet and yells, “You ALWAYS say that!“ in my general direction, I know he‘s okay. And we discuss that it’s okay to cry if it hurts, and together march through the house in search of the mandatory band-aid.)

So I‘ve been struggling with ways to link Lemony Snicket to medicine for the past few weeks. I tried to think about how we all make our living off a Series of Unfortunate Events, but that came out too morbid and seemed to be reaching for profundity when there was really none there. I thought maybe the anonymity of Lemony Snicket might represent a parallel to the uncertain nature of who or what is driving the health care system, but no matter how I turned it over in my head or on the page the topic never quite made sense. I even tried to derive an analogy between the main characters in the stories...the Baudelaire children and the Evil Count Olaf…but lost focus when the Count had morphed into Medicare Billing Guidelines and the infant Sunny became a pre-scandal Eliot Spitzer.

And late one night, as I finally gave up, I realized that for me, the failure to write is intellectual death. Most of us have probably run across the Kubler-Ross model somewhere in our training. It’s a five-step scheme for how we react to the prospect of death. In trying to get something to gel, I had gone through all the stages…denial, anger, bargaining, depression, and acceptance. And with acceptance came the idea that sometimes I might need to write about what I tried to do, and not what I did. Even a record of our unfulfilled hopes and aspirations can tell others more about who we are and what we believe than any catalog of diplomas or plaques on the wall.

Maybe I‘ve learned something valuable about futility. Maybe this piece should go into the Literary Hospice, be tucked into a nice warm bed, and given adequate pain relief until it expires of its’ own accord. Maybe futility is a lesson unto itself.

Besides, it’s time to ask the school questions again. Like I don’t know the answer.

(Afternote: This piece was originally written in the Spring of 2008…it’s amazing what one finds on the computer that never got published when digging through the pile of flash drives. Since then, there have been a few changes. The Nature Walk is now tolerated because we have a new Fate Worse Than Death in The Father-Son Bike Ride. And we no longer have Daddy and Boy Movie Night…the movies are still there, but I have made the transition from Daddy to Dad, which I think is the start of the change of the father image from Conquering Hero and Role Model to Annoying Guy with Money and Keys. But the more things change, the more they stay the same. He’s now in middle school…and still does nothing for seven hours each and every day.)

It has come to our attention that writers of better repute than myself have divined that the health care system in our blessed land…England, of course, for by the Grace of Our Lord no other land can be called as such with any sense of the honor imposed by the term…may someday cost our kingdom more than it does today. This hard to believe, for even the best life is worth no more than a pig and a farthing in the eyes of the physic, and is but half a thought in the mind of the Lord. Yet there are those, flushed with the bawdy proclivities and foolishness philosophies of the The French…natural rights, indeed… who predict a time when our colonies might dare to someday be independent and prosperous without the sheltering wings of our generous King, and who say that by the year 2006, should mankind still be upon this earth awaiting the rapture promised to us in the Gospels, that goodly band of rabble across the ocean may spend up to two trillion of their monies on health care each year.

Yet it is easy to recognize why this is so, as we walk about our homes and lands to see that followers of the Way of the Camel put Promethean fire to the tobacco leaves in our mouths; and that the hurly-burly of life, the hiss of the steam engine and the clatter of the coach traffic on the cobblestones streets, has caused many of us to worship at the altar not of the Almighty Jehovah, but at the King of Burger and his consort Wendy. And if we are to consider for a moment what may be next, just as the rebel Franklin talks about sparks from the sky as though they may be useful some day and the scornful idea of independence from their Mother Land…we might only expect these habits to worsen in our midst, until we eat foodstuffs on the advice of white suited colonels, makers of pommes frittes from Alba, and small canines of the new world speaking the Castilian tongue. We will chew leaves on the advice of Red Men and Bears of the North, and smoke products to remind us of fortunate moments at ninepins. Our machines will do our labor for us, and we will have no need for walking or exercise; we will become as a confined boar, growing larger yet losing our ferocity, until we are led meekly to the slaughter. We will develop disease such as the gout, which will make us immobile; we will develop dropsy, and our limbs will swell; we will find Hippocrates’ oncos and carcinos in our lungs, in our voices, in our mouths and noses; we will develop the disease of the honey urine, and lose the feelings in our limbs before the darkness envelops our eyes; our hearts will rise in defiant aggression and slay the body that bore it. The battle will be waged over many long and difficult years, and will cost us. Our purse will be poorer, and the costs will not be borne not only by the sufferer, but truly in every holt and heath.

But as we together lament the state of our wellness, and of our debts in this world and in the world to come, let us note the work of our Dutch colleagues (if such a continental can be called a colleague; still, Our Lord asks us to recognize good in all, even those who are not Loyal Subjects of Our Beloved King) who have used the bones of sheep and the motions of the stars to calculate the costs of living the life we seem destined to lead. They tell us that those who use the leaf of Raleigh and who revel in the kettled fat live less than those whose lives are a smokeless Spratt, but cost less, too. Those who live a more healthy life live longer, and cost more over their years than those who die sooner and quicker.

And so, my friends let us solve our problem in the most pleasant way. Let us smoke and drink, feast and sup, tell tales of humor, sagas of heroes, and legends of woe amidst the leafy haze of aromatic combustion; let us make merry. And let us die, quickly, painlessly, if the Lord grants us favor; but more likely hacking, coughing, suffocating as the malignant masses encases our lungs, or with the tense burden of Atlas falling onto our breasts, manifesting the weight f the world upon our arms and shoulders, giving off the sweat of honest labor as our heart takes that last…beat…beat…